Drinking water as an iron carrier to control anemia in preschool children in a day-care center

Iron-fortified water: a new approach for reducing iron deficiency anemia in resource-constrained settings

A new approach for fortification of drinking water is presented for combating iron deficiency anemia (IDA) worldwide. The idea is to leach Fe from a bed containing granular metallic iron (Fe0), primarily using ascorbic acid (AA). AA forms very stable and bioavailable complexes with ferrous iron (FeII). Calculated amounts of the FeII-AA solution can be added daily to the drinking water of households or day-care centers for children and adults (e.g. hospitals, kindergartens/schools, refugee camps) to cover the Fe needs of the populations. Granular Fe0 (e.g., sponge iron) in filters is regarded as a locally available Fe carrier in low-income settings, and, AA is also considered to be affordable in low-income countries. The primary idea of this concept is to stabilize FeII from the Fe0 filter by using an appropriate AA solution. An experiment showed that up to 12 mg Fe can be daily leached from 1.0 g of a commercial sponge iron using a 2 mM AA solution. Fe fortification of safe drinking water is a practicable, affordable and efficient method for reducing IDA in low-income communities.

Hearing loss in humans drinking tube well water with high levels of iron in arsenic-polluted area

Well water for drinking with increased levels of iron in arsenic-polluted areas has been reported worldwide. Oral exposure to arsenic has been shown to be associated with hearing loss, while there is no evidence for an association between excessive exposure to iron and hearing loss in humans. In this study, we determined iron and arsenic levels in biological samples and hearing levels by pure tone audiometry (PTA) in subjects in a control area and an arsenic-polluted area in Bangladesh. The iron level in well water in the arsenic-polluted area was significantly higher than that in piped supply water in the control area. Subjects in the polluted area (n = 109), who had higher iron and arsenic levels in hair and toenails than those in subjects in the control area (n = 36), had an increased risk of hearing loss at 8 kHz and 12 kHz after adjustments for age, gender, smoking and BMI. Significant associations of the exposure group with hearing loss at 8 kHz and 12 kHz remained after further adjustment for arsenic levels in toenails and hair. Thus, this pilot study showed that excessive exposure to iron via drinking water is a potential risk for hearing loss in humans.

Domestic Drinking Water—An Effective Way to Prevent Anemia among Low Socioeconomic Families in Brazil

Iron deficiency and iron-deficiency anemia are common in the developing world. We evaluated the feasibility of iron fortification of domestic drinking water to prevent and control iron deficiency and iron-deficiency anemia. Twenty-one families representing 88 persons, including children, were selected to participate in this study. Twelve families added an iron solution plus ascorbic acid to their domestic drinking water over a four months period and nine families added a placebo. Blood samples were collected, before and after the four months, for hemoglobin and serum ferritin measurements. Iron-fortified drinking water increased hemoglobin (children 10.9 ±1.1 g/dl to 11.7 ± 1.1 g/dl p < .01, adults 12.9 ± 1.7 g/dl to 13.7 ± 1.7 g/dl p < .01) and ferritin (children 27.6 ± 21.6 ng/dl to 33.8 ± 22.1 ng/dl, adults 74.8 ± 41.3 ng/dl to 106.2 ± 93.9 ng/dl p < .05). No significant changes in hemoglobin and ferritin were found in the placebo group after 4 months. Preparation, distribution, and consumption of the solutions were successful. Iron fortification of household drinking water can be a simple and effective alternative to deal with iron deficiency and iron-deficiency anemia in less developed areas.

Dietary Sources of Zinc and Factors Affecting its Bioavailability

Zinc is one of the more ubiquitous of nutrients, being found in modest amounts in a large number of foods. Human evolution has undoubtedly shaped the needs for zinc to be absorbed from our beverages and foods of both animal and plant origin in the diet. Different environmental and ecological circumstances modify the amount of zinc that needs to become available to individuals of different regions. We use an acronym approach to review and understand the bioavailability of zinc. The biological availability of zinc can be limited by many factors intrinsic and extrinsic to the host, and it can be enhanced by few. Challenges remain in assessing the bioavailability of zinc compounds as fortificants and in developing strategies to improve the uptake of the metal by reducing phytate and tannin content of diets, either through food technology or plant genetics.

Recent Experience with Fortification of Foods and Beverages with Iron for the Control of Iron-Deficiency Anemia in Brazilian Children

Iron-deficiency-anemia affects 30% of the world population. Women of reproductive age and children are the most affected. Iron supplementation in the form of tablets and syrups has not been successful in developing countries, and iron deficiency is still the most important deficiency related to malnutrition. Iron-deficiency anemia affects physical and cognitive development at an early age in children, often resulting in irreversible outcomes. Studies from the last two decades have shown that the prevalence of iron-deficiency anemia can be reduced given adequate investments and political will directed at iron fortification of foods and liquids. A successful low-cost iron-fortification program incorporates implementation and strategic use of communication for program inception where education is in the forefront. A review of the available reports from experience in Brazil with iron fortification of foods and liquids is presented.

Red meat snacks for chronic hemodialysis patients: effect on inflammatory activity (a pilot study)

RATIONAL

Among the alternatives to reverse chronic hemodialysis protein-energy malnutrition is the enhancement of intradialytic oral nutritional therapy. Although foods of animal origin are a source of nutrients and represent a feasible diet, there is uncertainty about their health consequences.

OBJECTIVES

We assessed the relationship of intradialytic high-protein red meat snack supplementation with patient inflammatory status and protein losses (nitrogen) during this supplementation. Fourteen patients submitted to low-flux chronic hemodialysis for one month were divided into two groups receiving 2 g (group 1) and 29 g (group 2) of oral intradialytic protein during the initial phase, respectively. In the subsequent phase, group 1 was supplemented with 27 g protein (a red meat snack) for a total of 29 g per dialysis. Group 2 continued to receive 29 g protein. Nutritional status, total nitrogen losses through the dialysate and acute inflammatory phase protein (CRP) were assessed before and after dialysis. Reuse of the dialyzer was also determined on each occasion.

MAIN FINDINGS

Red meat supplementation did not interfere with CRP, nitrogen loss through the dialysate (18 ± 7 to 19 ± 4 g in group 1, ns, and 20 ± 7 to 21 ± 4 g in group 2, ns) or with nutritional status. However, the data showed a positive correlation between pre- and post-hemodialysis CRP values (r = 0.84, p < 0.01) in both groups, suggesting an increase of the values after ultrafiltration. Reuse of the dialyzer was not correlated with CRP values.

PRINCIPLE CONCLUSIONS

The results suggest that snacks were not acutely correlated with increased inflammatory levels and indicated that a protein-rich red meat snack may be beneficial for chronic hemodialysis patients.

Iron-Fortified Drinking Water Studies for the Prevention of Children's Anemia in Developing Countries

Anemia and iron deficiency should receive special attention considering their high prevalence and serious consequences. For prevention, globally it is recommended to increase dietary iron intake, iron fortification of industrialized foods, and medical iron supplementation. Food fortification for the prevention of iron deficiency in developing countries should consider carriers locally available and consumed daily, requiring limited infrastructure and technology. Drinking water is the iron carrier we have been working for years for the prevention of iron deficiency and anemia in small children in Brazil. It was shown that studies with iron-fortified drinking water were proved to be effective on children's anemia prevention. Water is found everywhere, consumed daily by everyone may be easily fortified with simple technology, is low priced and was effective on the prevention of children's anemia. Fortification of drinking water with iron was locally implemented with the direct participation of the government and community. Government authorities, health personnel and population were part of the project and responsible for its community implementation. The mayor/municipality permitted and supported the proposal to supply it to children at their day-care centers. To keep the children drinking water iron fortified supply an officially authorized legislation was also approved.

Exposure to multiple metals from groundwater-a global crisis: geology, climate change, health effects, testing, and mitigation

This paper presents an overview of the global extent of naturally occurring toxic metals in groundwater. Adverse health effects attributed to the toxic metals most commonly found in groundwater are reviewed, as well as chemical, biochemical, and physiological interactions between these metals. Synergistic and antagonistic effects that have been reported between the toxic metals found in groundwater and the dietary trace elements are highlighted, and common behavioural, cultural, and dietary practices that are likely to significantly modify health risks due to use of metal-contaminated groundwater are reviewed. Methods for analytical testing of samples containing multiple metals are discussed, with special attention to analytical interferences between metals and reagents. An overview is presented of approaches to providing safe water when groundwater contains multiple metallic toxins.

Iron status of women is associated with the iron concentration of potable groundwater in rural Bangladesh

Women of reproductive age are at a high risk of iron deficiency, often as a result of diets low in bioavailable iron. In some settings, the iron content of domestic groundwater sources is high, yet its contribution to iron intake and status has not been examined. In a rural Bangladeshi population of women deficient in dietary iron, we evaluated the association between groundwater iron intake and iron status. In 2008, participants (n = 209 with complete data) were visited to collect data on 7-d food frequency, 7-d morbidity history, 24-h drinking water intake, and rice preparation, and to measure the groundwater iron concentration. Blood was collected to assess iron and infection status. Plasma ferritin (μg/L) and body iron (mg/kg) concentrations were [median (IQR)] 67 (46, 99) and 10.4 ± 2.6, respectively, and the prevalence of iron deficiency (ferritin < 12 μg/L) was 0%. Daily iron intake from water [42 mg (18, 71)] was positively correlated with plasma ferritin (r = 0.36) and total body iron (r = 0.35) (P < 0.001 for both). In adjusted linear regression analyses, plasma ferritin increased by 6.1% (95% CI: 3.8, 8.4%) and body iron by 0.3 mg/kg (0.2, 0.4) for every 10-mg increase in iron intake from water (P < 0.001). In this rural area of northern Bangladesh, women of reproductive age had no iron deficiency likely attributable to iron consumed from drinking groundwater, which contributed substantially to dietary intake. These findings suggest that iron intake from water should be included in dietary assessments in such settings.

Iron fortification strategies for the control of childhood anemia in Brazil

This article presents data on the fortification of foods, necessary as an important public health approach for the success in reducing anemia. The use of food vehicles, iron salts and their costs, as well as recent work on iron fortification of foods in Brazil are reviewed. Recent research serves as a cornerstone for countries that attempt to implement permanent, long-lasting iron fortification programs aimed at the prevention of anemia considering cultural habits, type of iron salts and at-risk groups.

Randomized controlled trial of iron-fortified drinking water in preschool children

OBJECTIVES

To evaluate the effects of fortified drinking water, with different concentrations of iron added, on hemoglobin and hematocrit values in preschoolers.

METHODS

Double-blind, randomized cluster clinical trial, with children aged 2 to 5 years of age, from 4 state-run schools, forming 1 group for each school. For fortification, ferrous sulphate in concentrations of 5 mg of elemental iron per liter of water (group A), 7.5 mg (group B), and 10 mg (group C), was used during a period of 4 months. In group D, the control, a placebo (Bixa orellana) was added. Hemoglobin and hematocrit values were checked before and after intervention.

RESULTS

Before fortification, hemoglobin and hematocrit averages were below the reference values adopted in all groups. After fortification, the prevalence of anemia showed a reduction in the 4 groups, which was more pronounced in group B, at 48.3%. The hemoglobin values in groups B (11.5) and C (11.4) were statistically similar. However, the average consumption of water/day/student was lower in group C. Comparison of hemoglobin values between groups A (11.2) and D (11.0) did not show a significant difference, suggesting insignificant efficacy with 5 mg Fe/L fortification.

CONCLUSIONS

The consumption of drinking water fortified with 7.5 mg of elemental iron/L water resulted in greater adhesion and an increase in hemoglobin values, with a reduction in the prevalence of anemia.

Aceitabilidade de pão fortificado com ferro microencapsulado por crianças de creches das regiões sul e leste da cidade de São Paulo

OBJETIVO: Avaliar a aceitabilidade de um pão tipo bisnaguinha enriquecido com ferro microencapsulado por crianças freqüentadoras de creches, de acordo com sexo, faixa etária, estado nutricional, presença de anemia, tempo de estocagem e momento do experimento (inicial, meio e final). MÉTODOS: Ensaio clínico randomizado duplo-cego com 382 crianças de 2 a 6 anos de idade, matriculadas em quatro creches filantrópicas do município de São Paulo. As crianças de duas creches receberam no café da manhã, de segunda a sexta-feira, o pão fortificado com ferro microencapsulado e as das outras duas, pão idêntico, porém sem ferro, durante 120 dias. A ingestão foi anotada diariamente em planilhas individuais. Os testes estatísticos utilizados foram o qui-quadrado, o teste t de Student, a análise de variância e a análise de covariância. RESULTADOS: O consumo médio semanal de pães foi significantemente menor nas crianças das creches expostas (1,17) do que nas creches não expostas (1,56) e a variabilidade de aceitação foi maior nas creches não expostas. A ingestão foi significantemente menor pelas crianças das creches expostas em todas as variáveis estudadas, exceto nas faixas etárias menores de 36 meses e de 36 a 47 meses. CONCLUSÃO: Apesar de a aceitação pelas crianças do pão fortificado com ferro ter sido significantemente menor do que ao pão sem ferro, a aceitação nos dois grupos mostra que este pão pode ser alternativa viável para a fortificação de alimentos na prevenção da anemia ferropriva em crianças de creches.

Fortification of Drinking Water to Control Iron- Deficiency Anemia in Preschool Children

Background

Iron-deficiency anemia is the most common type of micronutrient malnutrition in the world. Its etiology and control are well understood, but the problem persists and is increasing in some developing countries. Iron fortification of mass-consumption foods is considered one of the most viable approaches to deliver bioavailable iron to the population.

Objective

To review and analyze the use of drinking water as an iron vehicle to reduce ferropenic anemia in developing countries.

Methods

Drinking water with added iron compounds was offered to preschool children at day-care centers in Brazil. Iron solutions were prepared with 10 mg to 20 mg iron/L. Clinical and anthropometric measurements and blood hemoglobin concentrations were obtained at the beginning of each study and 4 to 8 months later.

Results

No problems with acceptability or side effects were observed. Daily water intake by children was around 500 mL. Iron-deficiency anemia was found in all studies. Control children not receiving iron sup- plementation mantained their initial hemoglobin level. Anemia was reduced in the groups receiving iron-fortified drinking water.

Conclusions

Based on physical properties, tests in rats, and studies on preschool children at Brazilian day-care centers, we have shown that drinking water locally fortified with iron compounds should be considered and used as a worldwide available vehicle to control iron-deficiency anemia. Drinking water, besides being universally available, is a locally available vehicle, easily fortified, can be a vehicle for hydrosoluble iron, and reduces iron-deficiency anemia in preschool children.

Anemia e renda per capita familiar de crianças freqüentadoras da creche do Centro Educacional Unificado Cidade Dutra, no Município de São Paulo

OBJETIVO: Avaliar a freqüência de anemia de acordo com a renda familiar per capita de crianças matriculadas no Centro de Educação Infantil (CEI) do Centro Educacional Unificado (CEU) Cidade Dutra, no Município de São Paulo, São Paulo, em 2004. MÉTODOS: Estudo transversal, com 190 crianças de 11 a 57 meses de idade distribuídas em duas faixas de renda familiar per capita (< 1 e > 1 salário mínimo). Foram consideradas anêmicas as crianças com taxa de hemoglobina <11g/dL, medida em amostra de sangue capilar digital por meio de fotômetro portátil Hemocue®. Na análise dos resultados foram empregados o teste do qui-quadrado e a análise de variância de Kruskal-Wallis. RESULTADOS: A anemia foi observada em 31,6% das crianças investigadas, sendo a sua freqüência significantemente maior nas crianças de menor faixa etária. A freqüência de anemia foi de 72,7%, 41,2%, 19,7% e 15,4%, respectivamente nas crianças de 11 a 23 meses, 24 a 35 meses, 36 a 47 meses e 48 a 57 meses. Entre as crianças de famílias com renda inferior a um salário mínimo, a freqüência de anemia foi de 36,7%, e naquelas com um ou mais salário mínimo, a prevalência foi 22,9%. CONCLUSÕES: Na creche do CEU Cidade Dutra, a freqüência de anemia foi maior nas crianças de 11 a 23 meses e nas famílias com renda per capita inferior a um salário mínimo.

Effect of Fortification of Drinking Water with Iron plus Ascorbic Acid or with Ascorbic Acid Alone on Hemoglobin Values and Anthropometric Indicators in Preschool Children in Day-Care Centers in Southeast Brazil

Background

Iron-deficiency anemia currently is the most frequently occurring nutritional disorder worldwide. Previous Brazilian studies have demonstrated that drinking water fortified with iron and ascorbic acid is an adequate vehicle for improving the iron supply for children frequenting day-care centers.

Objective

The objective of this study was to clarify the role of ascorbic acid as a vehicle for improving iron intake in children in day-care centers in Brazil.

Methods

A six-month study was conducted on 150 children frequenting six day-care centers divided into two groups of three day-care centers by drawing lots: the iron-C group (3 day-care centers, n = 74), which used water fortified with 10 mg elemental iron and 100 mg ascorbic acid per liter, and the comparison group (3 day-care centers, n = 76), which used water containing only 100 mg ascorbic acid per liter. Anthropometric measurements and determinations of capillary hemoglobin were performed at the beginning of the study and after six months of intervention. The food offered at the day-care centers was also analyzed.

Results

The food offered at the day-care center was found to be deficient in ascorbic acid, poor in heme iron, and adequate in non-heme iron. Supplementation with fortified drinking water resulted in a decrease in the prevalence of anemia and an increase in mean hemoglobin levels associated with height gain in both groups.

Conclusions

Fortification of drinking water with iron has previously demonstrated effectiveness in increasing iron supplies. This simple strategy was confirmed in the present study. The present study also demonstrated that for populations receiving an abundant supply of nonheme iron, it is possible to control anemia in a simple, safe, and inexpensive manner by adding ascorbic acid to drinking water.

Effect of Iron-Fortified Drinking Water of Daycare Facilities on the Hemoglobin Status of Young Children

BACKGROUND

Anemia is the most prevalent nutrition problem in young children. One possible strategy to prevent anemia is affordable fortification of drinking water.

OBJECTIVE

The aim of this study was to evaluate the impact of iron-fortified drinking water of daycare facilities on the hemoglobin and anthropometric status of pre-school children.

DESIGN

Hemoglobin (Hb) status, weight and height measurements were assessed in 160 pre-school children aged 6 to 59 m before and after 8 m consumption of iron- (12 mg/L) and vitamin C- (90 mg/L) fortified drinking water.

RESULTS

Initially, 43.2% (69) of the children evaluated as being anemic decreased to 21% (37) at the end of study. At baseline, 42 (26.3%) children suffered from moderate anemia and 27 (16.9%) suffered severe anemia, but after iron fortification, total number of children suffering from moderate and severe anemia had decreased to 32 (20.7%) and 5 (3%), respectively. Weight-for-age (WAZ), height-for-age (HAZ) and weight-for-height (WHZ) Z-scores increased significantly from -0.84 +/- 1.03 to 0.06 +/- 1.10, -0.84 +/- 1.11 to 0.54 +/- 1.10 and -0.39 +/- 0.94 to -0.18 +/- 1.14, respectively (p < 0.05). Daycare personnel reported increased appetite and food consumption and decreased absenteeism during intervention.

CONCLUSION

Daily consumption of iron-fortified drinking water in daycare facilities is an effective, simple and inexpensive means of reducing and controlling for moderate and severe anemia in pre-school children.

Fortificación de alimentos con hierro y zinc: pros y contras desde un punto de vista alimenticio y nutricional

La deficiencia nutricional de ciertos minerales como el hierro y zinc afectan a la población a escala mundial con graves efectos sobre la salud dependiendo fundamentalmente del grado de incidencia y de la magnitud de la deficiencia. La fortificación de alimentos ha resultado ser la estrategia más efectiva para corregir esta situación con inconvenientes que radican no solamente en la elección del alimento a utilizar como transporte para dichos nutrientes sino también en la correcta elección del compuesto a utilizar como fortificante ya que en general aquellos compuestos que poseen una adecuada biodisponibilidad presentan cambios en las características sensoriales de los alimentos fortificados poco aceptables para su consumo. Los compuestos inertes, que poseen propiedades optimas desde del punto de vista tecnológico poseen una baja absorción que los convierte en compuestos nutricionalmente poco útiles. En este trabajo se discute con mayor detalle estos aspectos con el fin de llegar a un entendimiento más profundo de la problemática antes mencionada.

Survey of trace elements in household and bottled drinking water samples collected in Riyadh, Saudi Arabia

Total dissolved beryllium (Be), cadmium (Cd), chromium (Cr), copper (Cu), iron (Fe), magnesium (Mg), manganese (Mn), mercury (Hg), nickel (Ni), selenium (Se), strontium (Sr), vanadium (V) and zinc (Zn) were measured in the drinking water of 101 households and 21 samples of retail bottled waters purchased in Riyadh, Saudi Arabia to ascertain the water quality for human consumption. The Inductively Coupled Plasma Spectrometer (ICP) was used for analysis. First-draw Fe, Mn, Ni and Zn concentrations decreased significantly after 10 min of flushing in the morning. Cd, Fe, Hg, Ni and Zn in some cases exceeded the guideline limits recommended by the EEC and WHO.

Iron fortification of domestic drinking water to prevent anemia among low socioeconomic families in Brazil

Iron deficiency anaemia is a most common micronutrient deficiency affecting mostly the low socioeconomic populations of the developing world. The objective of this study was to evaluate the feasibility of iron fortification of household drinking water to prevent iron deficiency anaemia among members of the low socioeconomic families of Southern Brazil. A total of 21 low socioeconomic families representing 88 subjects including 1-6 years old children whose haemoglobin level was between 10 and 12 g/dl were selected to participate in this study. Nine families in the control group were supplied with placebo solution and 12 families in the experimental group were supplied iron solution with ascorbic acid to be added to their domestic drinking water over a period of 4 months. The feasibility and acceptability of iron fortified drinking water was assessed through home visits and questionnaires. Blood samples were collected at the beginning and after 4 months of the study for the determination of haemoglobin and serum ferritin levels. The results of this study indicated that iron fortified drinking water was well received by the low socioeconomic families and that it was effective in improving the haemoglobin and serum ferritin levels. It can be concluded from this study that iron fortification of household drinking water is a simple and effective alternative for developing countries along with other technological approaches to iron fortification of foods.

Trace elements in drinking water coolers collected from primary schools, Riyadh, Saudi Arabia

A simple method for the spectrochemical analysis of water samples by inductively coupled plasma spectrometry is described. Samples from drinking water coolers in 32 schools in Riyadh were collected at a specific time during a typical school day and analyzed for aluminum (Al), beryllium (Be), cadmium (Cd), cobalt (Co), chromium (Cr), copper (Cu), iron (Fe), manganese (Mn), molybdenum (Mo), nickel (Ni), silicon (Si), strontium (Sr), vanadium (V), and zinc (Zn) to ascertain the water quality. The analysis of drinking water showed high concentrations of metals and in some cases exceeded the guideline limits recommended by EEC and WHO.